CCIS English In Action Application Form for 2017–2018

You will receive a copy of the information from this form by email from databaseadmin@CCISstanfordU.org shortly after you submit it. If you don't receive it, your email address must have been incorrect, or it was blocked by your spam filters--please fix the problem and try again! Please check the information, and either correct it yourself using the record key it contains, using the "EIA Client Applications" section of our website, or reply to it telling us any corrections you desire.

Please click on "Submit the data" only once. It takes a minute or so for the submit to happen, and if you click on "Submit the data" again during this time, it will create one or more duplicate records for you, which makes trouble for the system! Thank you!
CCIS Database Administrator

Information about person registering:
Grad Student Visiting Scholar Post-doc Spouse
Last Name First Name Spouse Last Name
(omit if same!)
Spouse First Name Greeting you prefer to see after the word 'Dear'
(e.g., Dear John,)
Street Address City State ZIP
Telephone Home number
e.g. 650-999-8888
 
Cell number
Work number
e.g. 408-999-7777x1234
 
Fax number
Email Address
Your gender: Male Female
Your age range: 20-29 30-39 40-49 50+
Do you have children with you in the US?: Yes No
If yes, please list their names, gender (M/F), and year of birth, one per line
e.g., Johnny, M, 2007:
Most of our volunteers find it too difficult to converse when small children are with you during the conversation time. We strongly recommend that you have someone else care for your children during your weekly conversation time.
Can you do that?: Yes No
Your preference (if any) for the gender of your conversation partner: Male Female
Your interests: Art American Culture Dancing Food Games History Movies
Classical Music Modern Music Playing (performing) Music Singing Music
Reading Photography Shopping Sports Technology Travel TV
Other Interests, or details (e.g., which sports?):
Your home country Job Experience
Your major field of study Department affiliation at Stanford (yours or spouse's):
When did you arrive in the US? How long do you expect to stay?
Which times are convenient for you to meet a conversation partner?: Weekdays Weekends Evenings
Are you able and willing to drive off campus to meet with your partner? Yes No
Are you taking English classes? Yes No
Return without submitting data